Peter Lachman @ Lean London Forum

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Developing Value through
the transformation of care
- what does it take?
Peter Lachman
Deputy Medical Director (Patient Safety)
Great Ormond Street Hospital for Children Foundation Trust
The case for change
Does the patient receive what is
recommended?
▫ 439 indicators of clinical quality of care
▫ 30 acute and chronic conditions, plus prevention
▫ Medical records for 6712 patients
▫ Participants had received 54.9% of scientifically indicated care (Acute:
53.5%; Chronic: 56.1%; Preventive: 54.9%)
Conclusion: The “Defect Rate” in the technical quality of American health care is
approximately 45%
Similar results reported for the UK
McGlynn, et al: The quality of health care
delivered to adults in the United States.
NEJM 2003; 348: 2635-2645 (June 26, 2003)
and 2006

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And how safe is health care?
“Americans do not use medical care more than others… they just pay
much more for the care they get.” - Washington Post, Aug 16, 2010

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Comparison of Spending on Health
(1980–2007)Total expenditures on health
(% of GDP)
Source: OECD Health Data 2009 (June 2009).
Why not just spend more?
Spending more does not improve quality
Source: Baicker K, Chandra A. Medicare spending, the physician workforce, and beneficiaries'
quality of care. Health Aff (Millwood). 2004 Jan-Jun;Suppl Web Exclusives:W4-184-97.
1940s- 60s
Onwards
2000s
1970s- 90s
60 plus years of the NHS
“Free at the Point of
Delivery”
Excellence defined
as knowledge
Delivery- focus on
quality and safety
Value for all

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Balancing the triangle
Healthy populations
Cost per person
over their life
Patient and
family experience
Value = Q/C
Q = Quality
C= Cost
Basis for change
The First Law of Improvement
“Every system is perfectly designed to
achieve exactly the results it gets.”
Batalden

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• Effectiveness
• Effectiveness
• Effectiveness
• Patient Centred
• Safety
The journey from evidence based medicine
to evidence based delivery to evidence based policy
Ref Mountford
What you get • Health policy builds health systems
to achieve maximum health benefit
and risk protection for population at
minimum cost
2010s
Impact on
clinicians and
their identity
• Evidence on what to do
• Knowledge has general
applicability
– Context systematically
stripped out
1990s
• Excellence defined as
knowledge
• See the world ‘one patient at a
time’
• ‘Patients with AMI should get drugs
X and Y’
• Evidence on how to organise so that
what we know gets done here reliably
and efficiently
• Knowledge has limited
generalisability
– Context explicitly built-in
2000s
Grounded in Additionally
• Ethics
• Politics
• Economics
• Biomedical model and statistics
• Analysis of few variables
• RCT is gold standard
methodology
Additionally
• Social sciences, including
– Management
– Leadership
– Organisation
• Operations
• Excellence is additionally in applying
knowledge
• See patients and populations
simultaneously
• ‘To reach optimal delivery for AMI in
this hospital we need to do X and Y’
• Excellence is additionally in
influencing system design,
stewarding resource and applying
knowledge to patients and
populations
• ‘The right system design and financing
for cardiac services here is. . .’
EBM EBM EBM
EBD EBD
EBP
Evidence-based
medicine
Evidence-based
delivery
Evidence-based
Policy
Add
Add
Data at GOSH
to follow

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Recommendation Current
Central management of admissions Yes …starting
Establishment of a central ‘patient flow team’ Yes
Central management of operationally-relevant information systems Yes
Improve collection and reporting of flow data Yes
Separate emergency and elective beds No
Separate resources for day case and inpatients +/-
Determine best management strategies for ‘high utiliser’ patients +/-
Reconfigure wards into larger units +/-
The future
• New CEO who is interested in lean
• Good foundation to address underlying variation
• Good data set available
• Now looking at case buy case variation